Valve-in-ring Research Articles

Predicting LVOT Obstruction in Transcatheter Mitral Valve Implantation: Concept of the Neo-LVOT

Outflow tract obstruction is a feared and potentially lethal complication of transcatheter mitral valve replacement (TMVR), mitral valve-in-valve (ViV), and valve-in-ring (ViR) procedures as well as implantation of transcatheter heart valves in calcific mitral valve disease. These procedures

First-in-man transcatheter mitral valve-in-ring implantation with a repositionable and retrievable aortic valve prosthesis.

Transcatheter interventions with balloon-expandable valves have been shown to be efficacious for the treatment of mitral annuloplasty failure but are limited by the fact that there is no opportunity for post-implantation adjustment. The aim of this study was to assess the safety and efficacy of the fully repositionable and retrievable Direct Flow Medical (DFM) valve for the treatment of mitral annuloplasty failure. Patients who underwent transcatheter mitral valve-in-ring (VIR) implantation of a DFM valve for failed mitral annuloplasty deemed high risk for redo surgery were included at four institutions. Eight patients underwent transcatheter mitral VIR procedures with implantation of the DFM valve. The DFM prosthesis was successfully positioned in all patients. Two patients required retrieval of the device due to a suboptimal result, and a further patient required repositioning of the valve with an ultimately successful implantation. During the 30-day follow-up period, two patients died for reasons unrelated to the valve implantation. The four patients with successful implantation had normal valve function associated with a significant improvement in their functional status. For the first time, we demonstrate the safety, efficacy and advantages of using the DFM prosthesis for the treatment of mitral annuloplasty failure.

New Self-Expanding Transcatheter Valve for Off-Pump Transatrial Mitral Valve-In-Ring Implantation

Objectives: To validate a self-expanding transcatheter valve for off-pump transatrial mitral valve-in-ring (VIR) implantation via a left thoracotomy. Methods: Mitral valve annuloplasty was performed via sternotomy during cardiopulmonary bypass on 9 pigs. After successful weaning from extracorporal circulation, the custom-made, self-expanding transcatheter VIR device was deployed under fluoroscopic guidance within the annuloplasty ring via a left thoracotomy. Hemodynamic data before and after the implantation were recorded. Mitral annulus diameter and valve area were measured by echocardiography. Transvalvular and left-ventricular outflow-tract pressure gradient were measured invasively. Results: Eight successful implantations were performed. Implantation failed in 1 pig because of difficulty with technical delivery of the sheath. Mean transatrial procedure time was 12.6 ± 1.7 min. Hemodynamic status during transatrial implantation was stable, and differences were not statistically significant. Mean mitral annulus diameter and mean mitral orifice area were 2.32 ± 0.2 and 3.84 ± 0.55 cm², respectively. Mild regurgitation was detected in 7 animals and moderate regurgitation in 1. Mean gradients were 6.1 ± 5.0 mm Hg across the device. Postmortem examination confirmed adequate positioning of devices within the annuloplasty ring. Conclusions: This custom-made transcatheter device allows for safe and reproducible off-pump transatrial mitral VIR implantations. Transatrial access is a promising route to facilitate VIR implantations. Our custom-made stent-valve may be suitable for VIR procedures.

Valve-in-valve apps: why and how they were developed and how to use them.

Rapid growth in transcatheter heart valve (THV) technology has led to its use in the treatment of degenerated bioprosthetic surgical heart valves (SHV) and failed mitral repairs. Multiple reports of valve-in-valve (VIV) and valve-in-ring (VIR) procedures have appeared in the literature during the last three years. The success of a VIV procedure is based on the correct identification of the surgical valve/ring, choosing the correct size of the THV and its subsequent accurate placement. There are, however, SHV and mitral rings implanted in the last two decades which differ in design, dimensions and fluoroscopic appearances. In the past, the users had to search through the literature to find out case-specific information. Unlike publications, by using the smartphone platform, we have collated vast amounts of available information, which can take the user through various links to present specific information about a clinical scenario relevant to their patient. Once downloaded, the information is available without the need for an Internet connection and can help in planning and performing a VIV/VIR procedure. The app platform also allows the addition of new material easily in the pre-existing user interface.

How should I treat prosthetic tricuspid stenosis in an extreme surgical risk patient?

A 64-year-old female with rheumatic heart disease and multiple prior valve replacements presented with progressive oedema, ascites and dyspnoea on exertion. Physical examination, transthoracic echocardiography, intracardiac echocardiography, transoesophageal echocardiography, right heart cathetherisation, computed tomography. She had a mitral homograft and Physio ring in the tricuspid position, and presented with severe bioprosthetic tricuspid valve stenosis (mean gradient 16 mmHg) and right-sided heart failure. A transcatheter 26 mm Edwards SAPIEN valve was placed in the tricuspid position, resulting in near normalisation of tricuspid valve gradient. This represents the first report of a combined valve-in-ring (VIR) and valve in a homograft valve (VIV) SAPIEN implantation.

Melody Valve-in-Ring Procedure for Mitral Valve Replacement: Feasibility in Four Annuloplasty Types

The recurrence of regurgitation after surgical mitral valve (MV) repair remains a significant clinical problem. Mitral annuloplasty rings are commonly used in MV repair procedures. The purpose of this study was to demonstrate the feasibility of transvenous valve-in-ring (VIR) implantation using the Melody valve (Medtronic, Minneapolis, MN), which is a valved-stent designed for percutaneous pulmonary valve replacement, and 4 distinct types of annuloplasty ring (AR) in an ovine model. Ten sheep underwent surgical MV annuloplasty ring placement (n=10): CE-Physio, Edwards Lifesciences, Irvine, CA [n=5]; partial ring [n=3]; flexible ring [n=1]; and saddle ring [n=1]). All animals underwent cardiac catheterization, hemodynamic assessment, and Melody VIR implantation through a transfemoral venous, transatrial septal approach 1 week after surgery. Follow-up hemodynamic, angiographic, and echocardiographic data were recorded. Melody VIR implantation was technically successful in all but 1 animal. In this animal a 26-mm partial AR proved too large for secure anchoring of the Melody valve. In the remaining 9 animals, fluoroscopy showed the Melody devices securely positioned within the annuloplasty rings. Echocardiography revealed no perivalvular leak, and angiography revealed no left ventricular outflow tract obstruction, vigorous left ventricular function, and no aortic valve insufficiency. The median procedure time was 55.5 (range, 45 to 78) minutes. This study demonstrates the feasibility of a purely percutaneous approach to MV replacement in patients with preexisting annuloplasty rings, regardless of ring type. This approach may be of particular benefit to patients with failed repair of ischemic mitral regurgitation.

Percutaneous Transvenous Melody Valve-in-Ring Procedure for Mitral Valve Replacement

The purpose of this study was to demonstrate the feasibility of percutaneous transvenous mitral valve-in-ring (VIR) implantation using the Melody valve in an ovine model. The recurrence of mitral regurgitation following surgical mitral valve (MV) repair in both adult and pediatric patients remains a significant clinical problem. Mitral annuloplasty rings are commonly used in MV repair procedures and may serve as secure landing zones for percutaneous valves. Five sheep underwent surgical MV annuloplasty (24 mm, n = 2; 26 mm, n = 2; 28 mm, n = 1). Animals underwent cardiac catheterization with VIR implantation via a transfemoral venous, transatrial septal approach 1 week following surgery. Hemodynamic, angiographic, and echocardiographic data were recorded before and after VIR. VIR was technically successful and required <1 h of procedure time in all animals. Fluoroscopy demonstrated securely positioned Melody valves within the annuloplasty ring in all animals. Angiography revealed no significant MV regurgitation in 4 and moderate central MV regurgitation in the animal with the 28-mm annuloplasty. All animals demonstrated vigorous left ventricular function, no outflow tract obstruction, and no aortic valve insufficiency. This study demonstrated the feasibility of a purely percutaneous approach to MV replacement in patients with preexisting annuloplasty rings. This novel approach may be of particular benefit to patients with failed repair of ischemic mitral regurgitation and in pediatric patients with complex structural heart disease.

Reducing operative mortality in valvular reoperations: The “valve in ring” procedure

FIGURE 1. Preoperative echocardiogram demonstrating a status-post mitral valve repair with severe mitral valve regurgitation. TEE, Transesophageal echocardiogram. Percutaneous valve therapy is an emerging therapy for aortic valve replacement in patients at high surgical risk. Favorable results have cautiously extended indications to high-risk patients with failing bioprostheses. Despite proven durability of mitral valve repair, some patients may require a reoperation and may represent a challenging surgical risk. The concept of ‘‘valve in ring’’ could be a solution for such patients, but this has, to our knowledge, been reported only in an experimental setting. We recently encountered a patient with failed mitral valve repair in whom a ‘‘valve in ring’’ procedure was performed.